Introduction

Approximately seven million people live in rural or remote areas of Australia (Australian Institute of Health and Welfare, 2022). Although there are many benefits to living rurally, such as shorter commutes to work and lower house prices, there are also disadvantages, including higher rates of alcohol abuse and poor health (Hazell et al., 2017). Compared to those who live in urban areas of Australia, rural Australians live shorter lives, have higher levels of disease and injury, and have limited access to health care services (Australian Institute of Health and Welfare, 2022). During the Growing Up in Queensland 2020 project, Queensland children identified that mental health was a significant barrier for their age group. They shared concerns about anxiety, depression, and body image, including body dysmorphia and how social media affected appearance and eating disorders (Queensland Family and Child Commission, 2021). Many first events can take place as adolescents develop into adulthood, such as moving out of the family home, beginning a relationship, alcohol, and drug use, starting employment, and facing the pressures of school and friendships (Handley et al., 2017). Support from health professionals, family and friends can make the transition easier for young people to have success and future opportunities. Unfortunately, throughout Australia, the level of mental health support is inconsistent, with adolescents living in rural and remote Queensland, continuing to face barriers that children in urban areas do not, such as more difficulty accessing experienced and qualified health professionals, and long waiting lists (Australian Institute of Health and Welfare, 2022). The literature that has been reviewed in this research project aims to identify how a lack of healthcare services can affect children and adolescents in Queensland. This includes identifying barriers that young people living rurally face when accessing healthcare and analysing what services and support are currently available to them.

Barriers that Young People Living Rurally Face when Accessing Healthcare

There are many discrepancies between health care in urban, rural, and remote areas of Australia. In 2021, over 65,000 Australians living rurally or remotely did not have access to a General Practitioner (GP) within an hour from their home, and nearly 107,000 people did not have access to any mental health services (National Rural Health Alliance, 2021). The Australian Bureau of Statistics (ABS) also reported that a lack of healthcare services, including GPs might account for the gap in mental health disorders between rural and urban communities (Peters et al., 2019). With young Queenslanders identifying that more education around mental health, easier access to support services and removing the association of shame around mental health disorders, as solutions to improving well-being (Queensland Family and Child Commission, 2021), it is difficult for these communities to move forward when there is a lack of support available.

Since the Covid-19 pandemic, many Australian residents have moved interstate. In March 2021, Queensland had 7,035 people migrate in from other states, 2,375 of them were aged between 0 – 24 years. New South Wales and Victoria both lost over eight thousand residents each, with 6700 of those people moving to Queensland (Australian Bureau of Statistics, 2021). With the population of regional and rural Queensland continuing to grow, young people are finding it even more difficult to access the mental health support that they need. With the population of regional and rural Queensland continuing to grow, young people are finding it even more difficult to access the mental health support that they need. Many health professionals in these areas no longer have their books open to new patients, due to being overloaded with current clients. They also have waitlists, with some people not being able to see their GP for at least two weeks. The Australian Psychological Society found that due to overwhelming demand, one in three psychologists are not taking new clients. Before the pandemic, it was 1 in 100 (Australian Psychological Society, 2022). Parents seeking support for their children can find it difficult to get any immediate action. A parent shared that when they tried to get help for their 14-year-old daughter, they were given three options. These were to wait 12 months to see a psychologist, go on medication or present to the emergency department at the hospital and state that their child showed signs of suicide ideation. With a lack of health care, it was not easy for the parent to get a second opinion, so they opted for medication as they thought going to the hospital would be too traumatic for their child (Kewley & Rizmal, 2022). A lack of mental health support providers can lead to young people taking medication for problems that could have been solved differently. However, at the time, they may feel that they do not have any other option. If people feel that they are not going to receive quality care or be placed on a waiting list, they may choose to not seek help at all (Smalley et al., 2012). According to the ABS, less than half of the people that experienced a mental health disorder in Australia sought treatment from a health professional (Australian Psychological Society, 2022). Although there are many factors as to why this may have occurred, including the Covid-19 pandemic restrictions on health services, social isolation, and economic hardship, research and studies indicate that this is not a new phenomenon, particularly in rural and remote Australia. According to the World Health Organisation (WHO), one in seven 10 -19-year-olds suffers a mental health disorder. If accurate support and treatment is not received, it can then lead into adulthood and affect future opportunities (World Health Organisation, 2021). Some common barriers that have been identified as to why a young person may not seek mental health support are; insufficient qualified health workers, not having reliable transportation to get to an appointment, frustration with waiting lists, a lack of after-hour care, confidentiality concerns and the stigma of seeking support in a small town where they believe people will gossip (Aisbett et al., 2007). It has also been identified that some people may not have the capability to identify that they need support or may have difficulties accessing a support service (Lawrence et al., 2015). All of these barriers can make it difficult for young people and their families to access the support that they need.

Another issue that is affecting rural communities is the high turnover rate of external agency staff. This has a flow-on effect, restricting the ability of health services to give high-quality support, which can then lead to health issues for people living rurally (Russell et al., 2011). Staff may also have a lack of experience or qualifications to support clients that need complex care, even though people who live in remote or very remote areas have a higher need for medical experts who are experienced in a wide range of practices, than people who live in urban areas (Australian Institute of Health and Welfare, 2022). There are many reasons why health workers choose to work in urban areas compared to rural and regional parts of Australia. These include a lack of training and professional development in rural practices, lower income, longer hours, and a lack of opportunities for their family members (Phillips, 2019).

Support Services Available to Support Young People in Rural and Remote Queensland

As children spend a significant amount of time at school, they play a pivotal role in supporting a young person’s mental health. Schools are a location where children and families can meet with healthcare services to receive assistance (Smalley et al., 2012). Support can be provided through a variety of methods, such as using telehealth to have appointments with paediatricians, providing a space for external support workers to meet with students, or speaking with school staff, such as a guidance officer, psychologist, or school nurse. Using the school premises as a base may relieve families of some of the stress that comes with transporting children to mental health clinics or coping with technological barriers. Schools are also ideal places to deliver mental health programs as they are safe and cost-effective environments (O’Connor et al., 2018). Evidence shows that children and parents often approach the school as a starting point for mental health support (Garbacz et al., 2022). School staff may also be the first to identify that a student may need emotional or behavioural support after observing them in the classroom or playground (Lawrence et al., 2015). Schools have the ability to communicate with students and parents and assist them to make connections with external service providers, whilst providing reasonable adjustments for the young person to ensure they have success at school.

Another support system for rural areas is online and telephone support networks. These services have increased in popularity over recent years, with 612,000 people using a phone or online service to speak to a health professional regarding their mental health in the past 12 months (Australian Government Department of Health and Aged Care, 2021). Evidence shows that these services play a significant role in supporting rural communities, however, not all people have the capabilities to access them. A report completed by Cavaye et al. (2020) for the University of Southern Queensland in 2021, assessed the social and economic impacts of digital connection in remote communities in far western Queensland (Cavaye et al., 2020). They found that with improved internet access, residents of these communities were able to video link with specialists in major cities and transfer large medical image files. However, one of the barriers that they noticed was the lack of digital literacy. Some people also feared technology and found it difficult to challenge themselves with something that they were not used to (Cavaye et al., 2020).

There are also many Non-Government Organisations (NGOs) that provide services for rural and regional areas. A report by the Centre for Rural and Remote Mental Health Hazell et al. (2017) states that the prevention of suicide in rural areas is not just the responsibility of Health Services and Mental Health services, but also the government, NGOs, rural and remote communities, and individuals (Hazell et al., 2017). Many NGOs run programs for rural communities. An example of this is the Deadly Thinking Youth program run by Rural and Remote Mental Health for Aboriginal and Torres Strait Islander communities on emotional well-being and suicide prevention. The workshops that they run are culturally appropriate and allow youth to share their stories in a safe and inclusive environment (Rural & Remote Mental Health, 2022).

Another critical service is the Royal Flying Doctor Service (RFDS). They provide retrieval and primary care services to rural and remote communities around Australia. The RFDS found that many of their call-outs were from areas that had limited mental health services (Gardiner et al., 2019). Gardiner et al. (2019) also found that the main causes were schizophrenia, bipolar affective disorder, depression, and misuse of substances, with 19.6% of those that misused psychoactive substances under the age of nineteen. Research completed by the RFDS found that the shortage of healthcare services discouraged people to not seek help until an incident was critical (Gardiner et al., 2019). They have also predicted that in 2028 there will be less than a fifth of GPs and a third of psychologists in remote areas, compared to those in urban areas (Gardiner et al., 2018).

The Australian Government Department of Health and Aged Care (2021) has tried to encourage health professionals to work in rural and remote areas by developing a Workforce Incentive Program and implementing other strategies such as financial incentives for healthcare workers and giving extra funding to services such as the RFDS. They have also improved bulk billing services and developed a Visas for GPs program to try and encourage overseas doctors to come to Australia and work rurally (Australian Government Department of Health and Aged Care, 2021). Although these measures are in place, there are still unacceptable discrepancies between urban and rural communities and the factors that affect children and adolescents from accessing mental health care There are still unacceptable discrepancies between urban and rural communities and the factors that affect children and adolescents from accessing mental health care.. Some of these factors include education, housing, community development and employment. Evidence shows that addressing these barriers may help to prevent mental health disorders and increase well-being (Fusar‐Poli et al., 2021). A report on mental health also found that if people have access to housing, employment and services that help them to integrate into the community, this can be more beneficial than healthcare in supporting their recovery (Productivity Commission, 2020).

The Impact of the Problem

Childhood is a critical time when mental health interventions can have the largest impact. 50% of lifetime mental health disorders begin before the age of 14, with 75% of the disorders starting before the age of 25 (Your town, 2022). In the second Australian Child and Adolescent Survey of Mental Health and Wellbeing, which was conducted in 2013–2014, 26.8% of parents and caregivers reported that their child needed support for behavioural and emotional needs (Lawrence et al., 2015). Yet only 42.9% of those people who sought help, had their needs fully met and 27.3% had their needs partially met (Lawrence et al., 2015). The survey also found that although mental health support needs were greater for children that lived outside of major cities, the number of those that received support was similar in both areas (Lawrence et al., 2015). With a lack of mental health support services available to rural communities, the impact of how this can affect children in the short and long-term future, and what measures can be put in place to support young people continue to be asked.

Research conducted by the RFDS shows that people who live in rural and remote Australia believe that the most critical issue that they will face in the next ten years is the growth of mental health problems and the lack of mental health services. (Gardiner et al., 2018) Young people and families that do not receive the mental health support that they need may face severe consequences in the future. It was reported that in 2019, there were 461 deaths by suicide in people aged 15 to 24 years (Australian Institute of Health and Welfare, 2021). Suicide is a leading cause of death in outer regional, remote, and very remote areas of Australia. (Australian Institute of Health and Welfare, 2022) Studies also show that indigenous suicide rates are not only significantly higher than non-indigenous people, but that indigenous people aged 15 to 24 years are five times more likely to suicide. From 2001 – 2010, the majority of indigenous suicides were outside of capital cities (Hazell et al., 2017). Unfortunately, in some circumstances, people must reach their breaking point to access the care they need. In the Rural Commission into Victoria’s mental health system, one of the key points was that finding help was difficult, with one person sharing that when they were trying to find mental health support, they were turned away as they were not suicidal enough (Armytage et al., 2021).

Another issue that young people face is the changeover from adolescence to adulthood. When they turn eighteen and transfer to the adult mental health system, there can be difficulties throughout this vulnerable time. The National Institute for Health Research in the United Kingdom describes ‘transition’ as being more than moving from one system to the next. Young adults require a support plan designed to meet their individual needs so that conditions do not worsen (Colizzi et al., 2020). Studies in America and the United Kingdom show that usage of mental health services declines dramatically when people turn sixteen and continue to drop even more so when they turn eighteen. Vulnerable young adults who do not have family support and have a mental health disorder are likely to continue to have emotional and social problems, such as lower educational achievement, a higher risk of self-harm and suicide, and are at a higher risk of unemployment, being homeless or being sent to jail (Singh & Tuomainen, 2015).

Mental health disorders cannot only negatively impact the person, but they can also affect the psychological well-being of other household members. Research conducted on rural families in New South Wales found that the more remote a family lived, the chances of parents being affected by their child’s mental health disorder increased. A lack of mental health support systems was suggested as being a factor (Novello et al., 2011).

The Potential Benefits for Rural and Regional Queenslanders if the Problem is Resolved

There are many benefits for a range of stakeholders if this issue is resolved. Children and adolescents with mental health disorders that live in rural or remote Queensland face many barriers to accessing the support that they need. If these barriers are not addressed, then young people can face an uncertain future. Vulnerable young people, who are not in education, training, or employment, often face social exclusion and have difficulty gaining experience and education for future employment (Gariépy et al., 2022). Research also shows that young people with mental health disorders are more likely to achieve low academically, become disengaged or get excluded from school (O’Connor et al., 2018). If the problem is resolved, then young people will have a better chance of completing school and moving on to training, education, and finding employment. Early intervention also decreases the likelihood of mental health disorders continuing into adulthood. Approximately 50% of adults with mental health disorders start to see signs as children (Paul, 2008). Evidence has shown that the disorder can increase in both seriousness and frequency for children and adolescents throughout their developmental years (Bartik et al., 2001). If young people are not getting the support that they need, it can be detrimental to how they develop and what their future path may look likeIf young people are not getting the support that they need, it can be detrimental to how they develop and what their future path may look like..

Another benefit of resolving this issue is the potential to reduce the demand for mental health services, which will in turn decrease waiting times and workloads for psychologists and counsellors. (Kewley & Rizmal, 2022) Many young people see waiting lists as a barrier, with some having their problems worsen during the waiting period (Leijdesdorff et al., 2021). If other service providers work collaboratively with health care providers, they may be able to address other concerns that young people have, which then may improve the young person’s well-being.

Rural and remote communities will benefit immensely as well. Poor mental health influences relationships and communication with others. Integration into a community can help to increase well-being and build connections. Groups such as the Men’s shed, sporting clubs and art programs can help people to form positive relationships with each other. This may also help to break the stigma in small communities around mental health disorders and encourage people to seek the help that they need. There are many elements in a community that can affect mental health, such as homelessness, employment, safety, and the economy. Many areas rely on local businesses and people to work, which may then influence social capital (Considine et al., 2019).

Discussion

Whilst the majority of literature related to mental health services in rural and remote areas focuses on the shortage of healthcare workers available; there is also an increasing amount of research on the benefits of promoting good mental health. This involves developing mental health literacy and decreasing inequalities that affect mental health, such as education, employment and housing (Fusar‐Poli et al., 2021). Evidence also shows that a future focus for young people and their well-being should be on prevention, with schools and other organisations supporting the social and emotional well-being of children (Productivity Commission, 2020). As the country continues to adapt after the pandemic, other factors must now be considered to ensure that young people who live rurally have opportunities to be successful, such as completing school, finding employment, and having suitable living arrangements. With all of these factors in mind, future research in this area could involve investigating how a person-centred approach can support the mental health needs of children and adolescents in rural and remote Queensland. This involves identifying how support services, schools, and other organisations can integrate to address all of the needs a young person may have.

Another gap that has been identified is the lack of research on how mental health disorders affect young people who live in rural or remote Queensland. A report by the Chief Health Officer on the Health of Queensland was completed in 2020. This report found that data related to Queensland children and mental health statistics was minimal (Queensland Health, 2020). A possible future research activity that could be integrated with the potential research area is to survey young people and families who live in rural or remote Queensland. This will ensure that the data collected to inform future decision-making is accurate and beneficial to the specific needs that young Queenslanders face.

Conclusion

Children and adolescents in rural and remote Queensland face many barriers that can stop them from receiving the mental health support that they need. Although some of these barriers are influenced by how they think other people, such as family, friends and the community will respond, a major barrier is a lack of qualified and experienced mental health professionals in rural and remote communities. Federal and state governments have developed programs to encourage Doctors, Nurses, and other health care professionals to work rurally; however, for reasons such as a lack of professional development and opportunities for their family members, the majority still choose to work in urban areas. Many organisations, such as the Centre for Rural and Remote Mental Health and the RFDS, service rural and remote areas of Queensland and try to ensure that all Australians have their mental health needs met.

Unfortunately, as there is a lack of data that focuses on Queensland children and adolescents living in rural areas, it is difficult to grasp a true understanding of how a lack of mental health services impacts them specifically. Although there is research available that represents Australia as a whole or other Australian states, data that represent Queensland is scarce, with most of the information available coming from surveying parents or caregivers, rather than the children themselves. In the future, it would be beneficial to conduct a research project that includes the voice of children and adolescents living in rural and remote Queensland areas to help identify the main barriers that they face in life and determine how other services, such as housing, education and healthcare can be collaborated to create support using a person-centred approach.

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